Pay for performance may have reduced UK mortality rates

The introduction in 2008 of a US-based "pay-for-performance" scheme into National Health Service (NHS) hospitals in the northwest of the UK resulted in a significant decrease in mortality rates, particularly for pneumonia, study findings show.

The overall 1.3% reduction in absolute mortality for the conditions included in the program equated to a relative reduction of 6.0%, or 890 fewer deaths, report the researchers in The New England Journal of Medicine.

While the largest reduction for a specific condition was for pneumonia, there were also nonsignificant reductions for myocardial infarction and heart failure, they add.

Although causality cannot be established from the findings, "the possibility of a substantial effect of the incentives on mortality cannot be excluded," say Matt Sutton (University of Manchester, UK) and co-investigators.

The Advancing Quality program was introduced in all 24 NHS hospitals in the northwest of England that provided emergency care. Only hospitals that reported quality scores in the top quartile received bonuses.

The researchers analyzed data from the 24 hospitals as well as 132 NHS hospitals in other regions of the UK, collected between 2007 and 2010. These covered three of the five clinical areas under the program: acute myocardial infarction (n=245,187 patients), heart failure (n=201,003 patients), and pneumonia (n=410,384). Data for 241,009 patients with conditions not included in the program were also used for comparison.

Overall, the reduction in mortality for conditions included in the program was greater in the northwest of England than in the rest of the country, decreasing from 21.9% to 20.1%, and from 20.2% to 19.3% for those regions, respectively.

This equated to a significantly greater 0.9% reduction in mortality in the northwest region for conditions included in the program compared with conditions not included, and compared with other regions of the country.

Furthermore, mortality was significantly reduced among patients with pneumonia, by 1.6% but only nonsignificantly reduced for those with acute myocardial infarction or heart failure, by 0.3% each.

After combining the two analyses (program conditions-other conditions and northwest region-other regions), Sutton and colleagues observed a greater, significant, 1.3% reduction in overall mortality, a significant reduction in pneumonia mortality and nonsignificant reductions in the other two conditions.

"Participating hospitals adopted a range of quality-improvement strategies in response to the program, including the use of specialist nurses and the development of new or improved data-collection systems linked to regular feedback about performance to clinical teams," explain the authors.

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